Claim Adjustment Grid – Medicaid

Submission Instructions – Use this form to submit multiple claim adjustment requests. Grid can contain up to fifty (50) claims with no attachments. This form is used to submit multiple claim adjustments. Once submitted, you will receive:

An immediate confirmation email
An acknowledgement email with a reference number and a copy of the original grid within 48 hours
A response to your grid within 30 days from the acknowledgement email date

Helpful Hint: if the description of issue applies to multiple claims, you can copy and paste to help speed up entry time. Fields indicated with a * are required fields.

Submitter's Name*
Email Address*
Provider Group*
Tax ID*
Is this adjustment request for services that denied for EVV?*
Is this adjustment request for services that denied for EVV? *
- Yes Note: Only providers rendering home care services should select “yes,” if applicable.
- No

List

Click + or - at the right to add up to 50 claims.

Short Description of Issue*	Claim ID (8 or 9 digits)*	Patient Acct #*	Patient Name*	Member ID (9 digits)*	From Date of Service (mm/dd/yyyy)*	Through Date of Service (mm/dd/yyyy)	Total Charges*: (enter as dollars and cents: xxx.xx)	Final Outcome (For NHPRI use only)

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